Cc OS - RADIOTHERAPY & CHEMO

• Cancer is a prevalent disease in the Philippines
• Cancer is the third leading cause of morbidity and mortality in the Philippines
• Annually, one out of every 1800 Filipinos will develop cancer
• Role of the dentist in managing the cancer patient

  • Detection of lesions
  • Surgical management
  • Pre-radiation protocols
  • Pre-chemotherapy protocols
  • Restoration and rehabilitation
• Radiotherapy


  Destroys neoplastic (and normal) cells by interfering with nuclear material necessary for reproduction, cell maintenance, or both
• Principle in radiotherapy


  • Faster the turnover the greater the destruction
  • Radiation damages both cancer cells and normal cells
  • Healthy cells able to repair
• Effects of Radiotherapy


  • Effects on the mucosa
  • Effects on the salivary glands
  • Effects on the bone
  • Other effects: effect on micro flora
• Taste alteration in radiotherapy

  • Taste buds are composed of epithelial cells
  • Affectation of salivary secretion also contributes to taste alteration
• Mucosal fibrotic change


  • Submucosal fibrosis is a long-term effect of radiation
  • Less pliable
  • Less resilient
  • Prone to trauma
  • Slow to heal
• Esthetic effect of fibrosis


  Radiation can cause severe fibrosis and contraction of muscles that can result in esthetic problems
• Radiation and trismus


  • Irradiated pterygomasseteric sling tends to be fibrotic and contract
  • Articular surfaces degenerate
• Radiation effects on bone

  Blood vessels are compromised, and necrosis of bone exposed to high-dose radiation therapy, resulting in decreased ability to heal if traumatized and in extreme susceptibility to infection
• Osteoradionecrosis


  Effect of radiation on bone
• Saliva has several important functions

  • Antimicrobial salivary proteins (peroxidase, lysozyme, lactoferrin)
  • Salivary mucins believed to protect teeth and mucosa against wear
  • Histatins have antifungal properties
  • Saliva aid in eating
• Effects on Xerostomia


  • Xerostomia makes eating difficult (dysgeusia, dysphagia)
  • Xerostomia causes difficulty in speech (dysphonia)
• Radiation caries


  Seen in the entire circumference of cervical portions of teeth
• Periodontitis


  Xerostomia increases the risk
• Candidiasis


  Radiation affects the oral flora, leading to opportunistic infections
• Factors to be considered in dental management of cancer patients

  • Present dental condition
  • Patient's level of awareness
  • Radiation schedule
  • Radiation location
  • Radiation dose
• Phases of Management


  1. Pre-radiation phase

  2. Intra-radiation phase

  3. Post-radiation phase
• The Pre-radiation Phase


  • Scaling and polishing
  • Encourage patient to stop smoking and drinking
  • Thorough radiographic and dental examination
  • Round sharp teeth
  • Apply pits and fissure sealants or preventive resin restorations
  • Replace old deteriorated restorations
  • Restore indicated carious conditions
• Endodontic intervention


  Conservation vs. Possible infection and/or osteoradionecrosis
• Considerations for pre-radiation extraction

  • Irradiation must be delayed for 3 weeks if possible
  • 7-14 days are acceptable if there is sufficient clinical evidence of healing
  • Generous bone removal should be done to allow coaptation of edges without tension
  • Premedication with antibiotics is advised to reduce risk of infection
  • Areas of exostosis may be prone to trauma and may have to be removed
  • Impression is taken for model cast to fabricate custom made trays for fluoride application during the course of radiation
• The Intra-radiation Phase


  • Prescribe soft diets and fluids
  • Mixture of antacid, diphenhydramine and lidocaine to minimize symptoms of mucositis
  • Products for Xerostomia (SalivaSure, Biotene, Salivart, Periowash, Glandosane)
  • Mouth rinses with chlorhexidine may prevent opportunistic infection
  • Infection with candida albicans can be managed with nystatin
  • Radiotherapy can result in fibrosis of the mucosa and muscles
  • Trismus resulting from mucosal fibrosis requires physiotherapy (therabite)
  • Fluoride treatment to prevent radiation caries
• Patient Management After Radiotherapy

  • Regular dental visits every 3-4 months with topical fluoride application
  • Tooth extraction after radiotherapy requires systemic antibiotics and hyperbaric oxygen
  • Vital pulp: immediate restoration with amalgam or composite, avoid full crown restorations
  • Non-vital pulp: endodontic treatment with systemic antibiotics
• Denture wear in the post radiotherapy patient

  • Altered bone remodeling
  • Timing: previously edentulous patient -6 months after radiotherapy, post-radiation extraction - at least one year
  • Denture design: occlusal force designed to distribute force evenly without lateral forces
• Management of Osteoradionecrosis


  • Discontinue use of denture
  • Irrigation
  • Sequestrectomy
  • Antibiotics: for wound <1 cm do not close, for wound >1 cm/non-healing do resection with primary closure
  • Hyperbaric oxygen
• Composite


  • Avoid full crown restorations
• Non-vital pulp


  Endodontic treatment required
• Denture wear in the post radiotherapy patient

  Altered bone remodeling
• Altered Bone Remodeling


  • Bone irregularities
  • Ulceration
  • Osteoradionecrosis
• Osteoradionecrosis


  • Infection
  • Further compromise remodeling
• Timing


  1. Previously edentulous patient: -6 months after radiotherapy

  2. Post-radiation extraction: -At least one year
• Denture Design


  • Occlusal force designed to distribute force evenly without lateral forces
• Stage I Osteoradionecrosis


  Exposed bone treated with 30 hyperbaric treatments preoperatively, followed by bony debridement, then 10 additional treatments postoperatively
• Management of Osteoradionecrosis


  1. Discontinue use of denture

  2. Irrigation

  3. Sequestrectomy

  4. Antibiotics

  5. Wound (<1 cm): Do not close

  6. Wound (>1 cm/ non-healing): Resection with primary closure, Bone grafting
• Stage II Osteoradionecrosis


  Do not respond favorably to 30 preoperative treatments, or when a more major operative debridement is required. Surgery must focus on preserving the integrity of the mandible.
• Stage III Osteoradionecrosis


  Patients have serious prognostic findings like pathologic fracture, percutaneous fistulae, and lytic lesions extending to the inferior border of the mandible. Mandibular resection is required, with all necrotic bone debrided and removed. Patients receive 30 preoperative hyperbaric oxygen treatments followed by 10 postoperative.
• Chemotherapy


  Faster dividing cells are more sensitive, including bone marrow, lining of stomach/intestines, mouth, and hair cells. Normal cells can repair themselves better than tumor cells.
• Effects of Chemotherapy


  • Bleeding tendencies due to bone marrow suppression
  • Infection
  • Oral mucositis